Comparing Peripherally Inserted Central Catheter Related Practices Across Hospitals with Different Insertion Models: A Multisite Qualitative Study

Abstract

Objective:

Peripherally inserted central catheters (PICCs) provide reliable intravenous access for delivery of parenteral therapy. Yet, little is known about PICC care practices or how they vary across hospitals. We compared PICC-related processes across hospitals with different insertion delivery models.

Methods:

We used a descriptive qualitative methodology and a naturalist philosophy, with site visits to conduct semi-structured interviews completed between August 2018 and January 2019. Study sites included five Veterans Affairs Medical Centers, two with vascular access teams, two with PICC insertion primarily by interventional radiology and one without on-site PICC insertion capability. Interview participants were healthcare personnel (n = 56) including physicians, bedside and vascular access nurses, and interventional radiology clinicians. Data collection focused on four PICC domains: use and decision-making process, insertion, in-hospital management, and patient discharge education. We used rapid analysis and a summary matrix to compare practices across sites within each domain.

Results:

Our findings highlight the benefits of dedicated vascular access teams across all PICC-related process domains, including implementation of criteria to guide PICC placement decisions; timely PICC insertion; more robust management practices; and, well-defined patient discharge education. We also found areas with potential for improvement such as clinician awareness of PICC appropriateness criteria and alternative devices, deployment of vascular access teams, and patient discharge education.

Conclusion:

Vascular access nurses play critical roles in all aspects of PICC-related care. There is variation in PICC decision-making, care and maintenance, and patient education across hospitals. Quality and safety improvement opportunities to reduce this variation are highlighted.

BACKGROUND

Reliable intravenous access is critical for delivering vital fluids and medications. Vascular access devices¹ are a ubiquitous part of hospital care. Central venous catheters (CVCs) that terminate in large vessels near the heart were once primarily found only in intensive care units (ICUs).^2,3 However, peripherally inserted central catheters (PICCs), which are safer to insert than traditional CVCs and enable outpatient parenteral therapy,^2,4 are now commonly found inside and outside the hospital setting.

Despite their popularity, information about PICC use, care and management, and patient education within and across hospitals is limited. Yet, these are critical domains for preventing serious complications, such as central line-associated bloodstream infection (CLABSI) and venous thrombosis. Emerging data suggest that implementing appropriateness criteria, which includes the use of alternatives such as midlines (devices that do not enter the central veins), can reduce PICC use and PICC-related complications.^{5, 6} Yet, how appropriateness criteria are used by different hospitals is not well-described. Studies also suggest that dedicated vascular access teams are associated with increased use of CLABSI prevention practices,⁷ and low rates of major complications.^{8, 9} Nonetheless, whether PICC-related care processes differ between hospitals with and without such teams has not been assessed. Finally, despite complication risks,^{10, 11} hospital variation in the education of patients about post-discharge PICC care has yet to be explored.

Data show that vascular access teams insert PICCs in approximately 60% of U.S. hospitals.⁷ Among hospitals without such teams, over 50% indicate PICCs are inserted by interventional radiology (IR). The number of hospitals without on-site PICC insertion is unknown but likely includes many smaller hospitals with low volume PICC use. Thus, the objective of this qualitative study was to describe and compare PICC-related processes across hospitals with different PICC insertion models. We were interested in how decisions about PICC use were made, the PICC insertion process, and practices related to in-hospital PICC management and patient discharge education as these are all key domains for ensuring the safe delivery of PICC-related patient care.

METHODS

Study Design and Sample

We used a descriptive qualitative methodology and a naturalist philosophy,¹² which involves studying something as it is in its natural state rather than using a specific theoretical or disciplinary perspective to study a phenomenon. This approach allowed us to develop an in-depth understanding of PICC-related processes as described by key informants in their everyday practice settings at five Department of Veterans Affairs (VA) Medical Centers.

Site visits, primarily to collect data through in-person semi-structured interviews, were conducted between August 2018 and January 2019. Sites were purposefully selected based on PICC insertion model (i.e., primarily inserted by vascular access team, IR, or no on-site insertion) to reflect models in use by U.S. hospitals. We identified a point of contact at each site, through colleagues in hospital medicine and infection prevention, who provided lists of potential interviewees involved with PICC insertion and care, including hospital medicine, surgery, critical care and infectious diseases physicians; medical/surgical, critical care and infusion center nurses; vascular access team members; and IR clinicians. We invited individuals from these lists, through email and by telephone, to participate in study interviews. This study was approved by the VA Ann Arbor Healthcare System institutional review board (IRB-2017–1038), with written documentation of informed consent obtained from interview participants by a member of the interview team.

Data Collection

The multidisciplinary research team developed a semi-structured interview guide (Supplement 1), consisting of questions related to our domains of interest: PICC use and decision-making process, PICC insertion, in-hospital PICC management, and patient education and post-discharge care. We focused on these domains given their link with PICC-related complications and patient safety.^{6, 13–16} Most interviews were conducted in person, by clinician and non-clinician interviewer pairs, during one to two day facility site visits by four members of the research team (SLK, MH, MQ, KEF or VC). Some interviews were conducted by telephone due to scheduling conflicts or because new key informants were identified during the site visit. Two of the interviews were conducted with the hospital point of contact but otherwise the interviewees did not know the members of the interview team. Interviews were audio recorded and transcribed verbatim.

Data Analysis

Cross-case analysis was conducted with each site considered an individual case study, allowing us to identify similarities and differences across hospitals with different insertion models and organizational features, as well as identify areas for improvement both within and across hospitals. A rapid analysis approach was selected given our objective was to describe and compare PICC-related processes across hospitals, and identify specific areas, within key domains, for subsequent improvement efforts or further study rather than provide an in-depth examination of more complex phenomenon surrounding PICC use.^{17, 18} We developed a summary template using each process domain represented in the interview guide. The site visit team used the template to create preliminary site summaries after each visit. Next, two other study team members (LEW, BG) individually reviewed interview transcripts to create detailed summaries for each participant. From the participant summaries, a detailed synthesis incorporating perspectives across professional roles was created for each VA Medical Center. The interview, preliminary and detailed site summaries were all reviewed and discussed during a series of meetings by the multidisciplinary research team to create a final summary for each site. The site-specific information was then transferred to a matrix to facilitate cross-case comparisons, highlighting similarities and differences across sites, within the four process domains. We established rigor throughout the study by involving researchers from different backgrounds (medicine, nursing, qualitative methods) in data collection and analysis, including discussing our own perceptions and potential biases based on clinical or personal experiences; by comparing similarities within and across interviewees involved in various aspects of PICC use; and, by looking for discordant evidence.

RESULTS

Characteristics of the five hospitals are shown in Table 1. Following our site selection criterion, PICCs were primarily inserted by vascular access nurses at the two largest sites (4 and 5), while PICCs were primarily inserted by interventional radiology at sites 1 and 2. However, we learned while scheduling the site 1 visit that IR was responsible for non-ICU patient PICC insertions, but ICU nurses with specialized training inserted PICCs for ICU patients. At the smallest hospital (site 3, average daily census of 46), PICCs were not inserted on-site. Of the 115 healthcare personnel contacted, 56 were consented and interviewed. A detailed description of interviewees and recruitment is provided in Supplement 2. Interviews ranged in number from 7 to 14 across sites and from 13 to 59 minutes in length.

Table 1:

Hospital Characteristics

	Site 1	Site 2	Site 3	Site 4	Site 5
PICC insertion model	ICU: PICCs inserted by trained nurses Non-ICU: PICCs inserted by interventional radiology	PICCs inserted by interventional radiology only	No on-site PICC insertion	Vascular Access Nurse Team	Vascular Access Nurse Team
Average daily hospital census for October-December 2018	132	53	46*	252	180
Census Division	East North Central	West North Central	East North Central	West South Central	South Atlantic
Number of interviews completed	10	14	7	13	12

ICU = intensive care unit; PICC = peripherally inserted central catheter.

^*Mostly inpatient mental health with a reported average daily census of about 4 acute care medical patients

Our main findings within each process domain: decisions about PICC use, insertion process, in-hospital management, and patient discharge education, are discussed in detail below with a focus on notable differences and common challenges across sites.

PICC Insertion Decision

The PICC insertion decision includes the personnel involved, criteria for determining appropriateness, and the availability of alternative vascular access devices. Three primary differences were found across sites as summarized in Table 2.

Table 2:

PICC Insertion Decision

Site Insertion Model	Who is Involved in Insertion Decision	Criteria for PICC Use	Availability and Use of Alternatives
Site 1 ICU: Trained ICU PICC nurses Non-ICU: Interventional Radiology (IR)	ICU patients: Collaboration between ICU physicians and ICU nurses who place PICCs Non-ICU patients: Ordering clinician sends consult to ambulatory infusion nurse who reviews then sends to IR Specialist involvement variable	No formal use criteria IR clinicians and ICU PICC nurses aware of the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC); ordering clinicians were not; ambulatory infusion nurse uses general rules of thumb	Midline catheters available for use by IR but ambulatory infusion nurse thought midlines were minimally useful and not likely to recommend ICU PICC nurses not aware that midlines were available
Site 2 Interventional Radiology (IR) only	Ordering clinician sends consult to IR Infectious diseases typically involved if indication is antibiotics; oncology if chemotherapy; and, nutrition if TPN	No formal use criteria General lack of awareness of MAGIC Ordering clinicians thought IR confirmed appropriateness; IR thought ordering clinician verified appropriateness	Midlines not available, will trim PICC to create if needed (e.g., stenosed vein)
Site 3 No on-site insertion	Ordering clinician sends consult to another VA Medical Center or contacts a local community hospital Specialist involvement limited	No formal use criteria Ordering clinicians not aware of MAGIC	Midlines or other alternatives not available on-site and ordering clinicians were not familiar with these devices
Site 4 Vascular Access Team (VAT)	Ordering clinician sends PICC consult to VAT who reviews, contacts clinician if not appropriate, suggests alternative Infectious diseases involved if indication is antibiotics; nutrition for TPN; nephrology if renal patient; IR involved when VAT unable to insert PICC	VAT uses MAGIC to assess PICC appropriateness; some ordering clinicians aware of MAGIC as PICC order includes pop-ups with special considerations for patients with end-stage renal disease and infectious diseases consult if being used for antibiotics	Midlines, ultrasound guided peripheral IVs and tunneled catheters available VAT favored midlines or ultrasound guided peripheral IVs for shorter duration, non-vesicant access needs. Clinician views of midlines were mixed
Site 5 Vascular Access Team (VAT)	Ordering clinician sends consult to VAT who reviews, determines appropriate device, contacts clinicians if different from what was ordered Infectious diseases involved if indication is antibiotics; nutrition for TPN; use lab criteria for when to involve nephrology; IR involved when VAT unable to insert PICC (2 failed attempts or patients with history of difficult insertion)	VAT uses criteria adapted from MAGIC to determine appropriate device; ordering clinicians generally not aware of MAGIC PICCs required for patients discharged to skilled nursing facilities while receiving IV medications	Midlines, ultrasound guided peripheral IVs and tunneled catheters considered as alternatives VAT expressed disappointment with using midlines due to poorer line function (e.g., kinking, difficulty with blood return after several days of use)

ICU = intensive care unit; IR = interventional radiology; IV = intravenous; MAGIC = Michigan Appropriateness Guide for Intravenous Catheters

PICC = peripherally inserted central catheterTPN = total parenteral nutrition; VAT = vascular access team

The first difference is the extent to which medical subspecialists were involved in the decision process. At three hospitals, including both with vascular access teams (4 and 5), subspecialists played a role in the insertion decision when specific populations or indications arose, e.g., infectious diseases (ID) when the indication for use was intravenous antibiotics, or nephrology for patients with renal dysfunction. As one vascular access nurse at site 5 described:

We used to stick, put PICC lines in the renal patients, what we’re finding is when the patients are finally getting to dialysis, the dialysis catheters, the fistulas are not lasting, they’re crashing faster than ever and I give renal credit because they [renal] really stepped up to put their foot down and make sure those arms are protected.

At sites 1 and 3, subspecialist involvement in the decision process was more variable. At site 1, when asked about involvement in the decision-making process, one ID physician responded:

Yeah, it varies. … early on when I first started the majority of time like PICCs were already going, like in. But now that we’ve had this kind of stronger presence I would say that I think that they’re a little bit better because sometimes they’ll call and then ‘we’re like we’re putting in the order for the PICC line’.

The second difference involved awareness and use of criteria for decisions regarding PICC appropriateness. While awareness of appropriateness criteria varied across sites, only hospitals with vascular access teams reported explicitly using such criteria to guide decision-making. Conversely, at hospitals without a vascular access team (sites 1, 2, 3), formal criteria to guide decisions did not exist. As described by IR clinicians at site 1:

She’s [ambulatory infusion nurse] really the triage person that says, okay what kind of line … I asked her if she had like a algorithm she follows because we’re doing this at the main [academic] hospital … and she doesn’t. She’s just done this for so long she just sort of knows the flow of things. Consult goes to [ambulatory infusion nurse], she gathers that information. She puts it on the order and then sends it to us. We review it to make sure it’s appropriate. … [Interviewer: And do you use specific criteria to decide when it’s appropriate?] Yeah, well we try to follow the MAGIC guidelines.

Vascular access nurses were using the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) to determine device appropriateness at both vascular team hospitals. However, ordering clinicians across all sites were often not aware of these criteria except for a few clinicians at site 4, where MAGIC had been incorporated into the electronic order set.

… our order set has been changed where now you have to, and it’s in many of the same categories that are on the MAGIC criteria where you have to click, you know what it is that you’re using that access for. [hospitalist, site 4]

The third difference was the availability and use of potential PICC alternatives (e.g., ultrasound guided peripheral IVs, midlines). Three sites had alternatives available routinely, two did not. Consequently, knowledge about, and perceived utility of alternatives varied across sites. At sites 2 and 3, alternatives were not generally available and ordering clinicians were not familiar with devices such as midlines. However, even at sites with alternatives, placement varied based on perceived usefulness. For example, at site 1, midline availability was not common knowledge and the nurse who reviewed PICC consult requests did not have a favorable opinion about their usefulness. At site 5 the vascular access team used midlines occasionally but expressed concerns about functionality. As one site 5 vascular access nurse described:

… if I go down to bedside and the nurse says, “Let’s put an IV in,” and the doctor will say, “Well, let’s look at the patient for a midline,” I look at them and think, “Okay, if he’s going to be here for the next week and that midline can fail in 2 days because it’s an IV, it’s a long IV,” then I, a lot of times end up jumping over in going to a PICC line.

In contrast, the vascular access nurses at site 4 were enthusiastic about using midlines or ultrasound guided peripheral IVs when appropriate.

… the number of PICCs trending down, that’s what I want it to be and the midline is, the midline also is just, just evened out but the peripheral IV, peripheral IV ultrasound guided like goes up like probably triple the number. [vascular team nurse, site 4]

PICC Insertion Process

While the type of providers inserting PICCs differed across sites in accordance with our sampling frame, concerns about provider availability and care delays were described at all sites (Table 3). These challenges were especially prominent at certain hospitals. For example, at site 2 where only IR clinicians placed devices, PICCs were not inserted after 4PM or on weekends and patients with PICCs ordered on a Thursday or Friday could have a two to three day insertion delay.

Table 3:

PICC Insertion Process

Site Insertion Model	Who Performs Insertions	Scope of Coverage	Patient Care Challenges
Site 1 ICU: Trained ICU PICC nurses Non-ICU: Interventional Radiology (IR)	ICU patients: Specially trained ICU nurses perform bedside insertions using an EKG tip positioning system Non-ICU patients: IR inserts in IR suite	ICU nurses only available during scheduled nursing shift so can be times when none are working (no 24/7 coverage) IR insertion during the day, not available evenings, weekends, holidays potentially leading to delays in insertion	If ICU PICC nurse not available, patient could be sent to IR or must wait until next able nurse is working IR insertion requires scheduling and patient transport, which had to be coordinated. Also, delays could occur for patients with consults placed during off-hours
Site 2 Interventional Radiology (IR) only	IR physician and residents insert primarily in IR suite, with bedside insertion available for critically ill patients who cannot be transported	IR is not a 24/7 service. No insertions after 4PM or on weekends. IR providers are on call but cannot be called in for PICC insertion	Insertion in IR may be scheduled in advance but can also occur whenever IR has available time. Can be insertion delays given lack of 24/7 IR availability. The time between PICC order and insertion can increase during the week, with same or next day insertion at the beginning of the week and a 2–3 day wait if ordered on Thursday or Friday
Site 3 No on-site insertion	Vascular access team (VAT) at another VA Medical Center (approximately 90 miles away) Providers at 1 of 3 local community hospitals	VAT available during regular business hours (no 24/7 coverage) but can take 2–3 days to get an appointment Local provider availability not discussed but indicated that insertion usually occurred within 2 days	Insertion delays while appointments are scheduled. Travel to VA Medical Center 4-hour drive round trip in an ambulance. 30–40 minutes to local facility. Both require nursing staff to accompany the patient
Site 4 Vascular Access Team (VAT)	VAT performs bedside insertion using an EKG tip positioning system IR inserts in IR suite if VAT is not able to successfully insert at bedside	VAT available 0730–2000 each day, including availability on weekends and holidays. Goal to become 24/7 service IR available during regular business hours, not a 24/7 service	Little delay with insertions by VAT, may have to wait until next morning depending on when the consult is placed Potential delay if IR insertion is required, especially evenings or weekends, may have to wait until next business day
Site 5 Vascular Access Team (VAT)	VAT performs bedside insertion using ultrasound doppler imaging technology IR inserts in IR suite if VAT is not successful after 2 attempts	VAT available 0530 to 2300 on weekdays, on call on weekends. Was 24/7 service but decreased time based due to productivity IR available during regular business hours, not a 24/7 service	VAT required to insert within 2–3 hours of the order being placed, may be some delay if during off-hours Some delays in IR insertion if during off-hours

EKG = electrocardiogram; ICU = intensive care unit; IR = interventional radiology; PICC = peripherally inserted central catheter; VAT = vascular access team

…we just have interventional radiology that does it. And if they would need it on the weekends good luck because we don’t always have call, we do have call but we don’t, I don’t get it. [bedside nurse, site 2]

The impact on patient care was even more pronounced at the hospital without on-site insertion (site 3), requiring days for appointment scheduling and an ambulance ride of 30 to 40-minutes round trip if transported to a community hospital or four hours if transported to the nearest VA Medical Center.

Finally, while site 4 was expanding on-site vascular access team availability, site 5 was reducing the team’s on-site presence, with the impact on care delivery noted for both scenarios. According to a hospitalist at site 4:

… they have really expanded the availability of the vascular access team and so I don’t know if they’re here 7 days a week, but they’re definitely here one of the days on the weekend, they’re here on holidays, they’re here for an extended period of time and so it has made things so much different because I feel there’s a lot of patients who before there would be, you know the back and forth between nurses and physicians and access is poor and now a lot of them, we’re just calling the vascular access nurses …

In contrast, at site 5:

… in the last month or two months, we don’t have anybody on the weekend, we have to call them in. Usually they were on all the time, we had them over the weekend as well and we could put stuff in. [hospitalist, site 5]

In-Hospital PICC Care and Removal

At all hospitals, registered nurses (RNs) were responsible for in-hospital PICC care. However, which nurses performed which tasks and whether nurses could perform certain tasks differed across hospitals (Table 4). At site 1 a dedicated IV team assumed sole responsibility for managing PICCs 24/7. At the hospitals with vascular access teams (sites 4 and 5) responsibility for PICC care was shared, with bedside RNs conducting assessments, blood draws and as-needed dressing changes, while vascular access nurses conducted daily assessments, flushes and weekly dressing changes. Vascular access nurses were also responsible for troubleshooting when PICCs were not functioning properly and, if necessary, administering tissue plasminogen activator (tPA) to clear an occlusion and restore patency.

Table 4:

In-Hospital PICC Care and Removal

Site Insertion Model	Who Provides PICC Care	Scope of practice	Removal Authority
Site 1 ICU: Trained ICU PICC nurses Non-ICU: Interventional Radiology (IR)	IV team Registered Nurses (RNs) are responsible for all PICC care (24/7) including dressing, flushing and troubleshooting	Assess PICCs daily, monitor for infection, draw labs, perform weekly and as needed dressing changes Manage most complications, including flushing, troubleshooting and administration of tPA	ICU nurses who insert PICCs can remove if ICU patient IV team RNs can remove for non-ICU patients
Site 2 Interventional Radiology (IR) only	Bedside RNs are responsible for all PICC care	Assess PICCs each shift, monitor for infection, flush, draw labs, perform weekly and as needed dressing changes Nurses contact physician about any complications, can administer tPA with physician order	ICU nurses may remove PICCs for ICU patients Only physicians can remove PICCs for non-ICU patients
Site 3 No on-site insertion	Bedside RNs are responsible for all PICC care	Assess PICCs each shift, monitor for infection, flush, perform weekly dressing change Inconsistent reports about RNs drawing labs, some said not authorized, one said recently authorized Nurses report complications to physicians, tPA not available on site so clotted lines may just be removed	Physicians can remove, some discrepancy about whether RNs could remove PICCs General agreement about limited removal opportunity so competency concerns with both physicians and nurses Patients may be sent to another facility for removal
Site 4 Vascular Access Team (VAT)	Bedside RNs and VAT share responsibility for PICC care	Bedside RNs conduct as needed PICC care, infusions and draw labs VAT conducts daily assessment (Monday-Friday), flushes and weekly dressing change; contacted about complications, assist with troubleshooting, difficult blood draws, and administer tPA with physician order	VAT responsible for most PICC removals, physicians may remove if no team member on site or in some units (e.g., ICU) for training purposes. Some bedside nurses also trained to remove PICCs
Site 5 Vascular Access Team (VAT)	Bedside RNs and VAT share responsibility for PICC care	Bedside RNs assess for signs of infection, draw labs, perform as needed PICC care, including dressing changes and flushing VAT assess and flush PICCs each weekday and perform weekly dressing change; contacted about complications, troubleshoot and when needed can order and administer tPA	VAT responsible for most PICC removals, physicians must remove if removal is due to deep vein thrombosis Some bedside nurses also trained to remove PICCs if VAT not available at time of patient discharge

ICU = intensive care unit; IR = interventional radiology; IV = intravenous; PICC = peripherally inserted central catheter; RN = registered nurse; tPA = tissue plasminogen activator; VAT = vascular access team

Well, they [bedside RNs] do PRN [as needed], we [vascular access RNs] do dressing changes for the entire hospital every Thursday … But we audit the lines every day. Monday through Friday we go and look at the dressings, we flush the lumens, make sure that they’re patent. If they are not, you know we recommend that they get the Alteplase, have the doctor put the order in and then we’ll de-clot them … [vascular team nurses, site 4]

At sites 2 and 3, bedside nurses had to contact a physician about any complications and, at site 2 could administer tPA only with a physician order. At the hospital without on-site insertion capability (site 3), tPA was not available so clotted lines had to be removed.

The process for in-hospital PICC removal also differed across hospitals. While physicians were the primary decision makers regarding removal at all hospitals, at site 4 the vascular access team conducted regular reviews and prompted device removal when needed. As described by the vascular access nurses:

every week we have a huddle with our boss [team manager], and then we go over and say like, “Well, there’s a PICC line, do we have medication going on? We don’t have medication going on, if there’s nothing there, it doesn’t qualify to keep it right there,” and sometimes the primary nurses would say that you know patient is a hard stick and we need to draw blood … So, we had to tell them that, “Hey, you don’t go do your home grocery in 18-wheeler, you know?” [all laugh] That’s something like if you’re trying to keep a central line in just to draw blood, it’s pretty much like that, you know.

At sites 4 and 5 vascular access nurses also had primary responsibility for physically removing PICCs, although both hospitals were training bedside nurses to remove PICCs if a vascular access nurse was not available.

then to DC [discontinue] a PICC, we have nurses on the floors that are checked off to do it. We used to do them all because in the past, well-meaning nurses have pulled PICC lines out when patients were going home not realizing they were going home with a PICC line and we’ve had to replace them. So, the fix was IV [vascular] team only …, but nowadays if we’re busy the nurses that are checked off can … [vascular team nurse, site 5]

At site 1, ICU nurses who inserted PICCs were responsible for removal in ICU patients, while dedicated IV team RNs had primary responsibility for removal involving non-ICU patients.

At the two sites without a vascular access or IV team, physicians played more of a role in the removal process. ICU nurses could remove PICCs for ICU patients at site 2, but only physicians could remove for non-ICU patients. The challenge at site 3, where physicians were responsible for PICC removal, was the lack of physician competency given this was a low frequency event.

nurses are not allowed to remove PICC lines here. It has to be a physician. And it’s frustrating because like if [Hospitalist physician] is on vacation the doctors that come over here don’t know how to do it. … two PICC line people ago I had to walk the doctor [through] how to pull out a PICC line. And like, I can’t do it but you can and you have no clue how to do it. [bedside nurse, site 3]

Patient Discharge Education and Post-Discharge Management

We found substantial differences in patient discharge education and post-discharge management as described in Table 5. In general, hospitals with vascular access teams (sites 4 and 5) had better-developed discharge teaching approaches. However, there was no standard education or home discharge process across sites. At sites without such teams, bedside, discharge and/or infusion center nurses were responsible for education. The type of education ranged from an informational handout only (site 3) to educational materials plus skills-based instruction, use of visual aids, and hands-on teaching (sites 1, 4 and 5).

Table 5:

Patient Discharge Teaching and Post-Discharge Management

Site Insertion Model	Who Provides Discharge Education	Discharge Education Content	Home Care and Discharge Instructions
Site 1 ICU: Trained ICU PICC nurses Non-ICU: Interventional Radiology (IR)	Ambulatory infusion nurse or IV team nurse	Not standard, line flushing, basic care included.	Home care provided, for some, by contract home care agency. Told to call the IV team with any device problems after discharge.
Site 2 Interventional Radiology (IR) only	Discharge nurse	Signs and symptoms to watch for	Home health nurses responsible for home monitoring. Patients told to contact home health about problems after discharge.
Site 3 No on-site insertion	Inpatient nurse responsible for patient discharge	Education sheet with basic device information from referral site that placed the PICC	Social work schedules home care with contracted agency. Instructed to contact home health provider, telephone triage line or go to urgent care for problems after discharge.
Site 4 Vascular Access Team (VAT)	VAT	Line care basics, scrub the hub and pamphlet on what a PICC is, why it’s used, what to do if it gets wet or pulled out, how to care for it at home	At discharge, a home health nurse comes to the facility for a warm handoff. Pamphlet also contains vascular team contact information.
Site 5 Vascular Access Team (VAT)	VAT	Pre-insertion video, booklet on flushing, basic line care, and dressing protocols	Some have home care; all are instructed to call the vascular team if they have any questions.

ICU = intensive care unit; IR = interventional radiology; PICC = peripherally inserted central catheter; VAT = vascular access team

We have PICC education videos that are available on every TV. They’re a few minutes each and one is from, you know what is a PICC line to what, how to take care of a PICC line at home, signs and symptoms, what to do after it’s taken out, you can run them in a series and it’s 15 minutes total. … We’ll teach them about the flushing, watching for the blood returns, any problems with the PICCs, if the PICC comes out, when to call us, when to come in … [vascular team nurse, site 5]

Finally, all sites indicated that home care agencies provided care for some, but not all, patients after discharge. Only site 4 described a process in which the home care nurse came to the hospital prior to patient discharge. According to a nurse case manager at site 4:

…once they received the referral, that [infusion company] nurse will come on-site and she’s going to teach the patient and/or caregiver the initial process … Which is great because that’s a clean handoff…

The home care agency, when provided, was the primary point of contact for patients should they experience PICC problems after discharge. However, at sites 4 and 5, patients were also given contact information for the vascular access team, whereas IV team information was provided at site 1. At site 3, patients were instructed to go to urgent care for device-related issues.

DISCUSSION

We sought to describe and compare PICC-related processes across hospitals with different PICC insertion models, given PICCs are a vascular access mainstay but require appropriate use and management to reduce the risk of serious complications. Our study characterizes PICC-related processes across five diverse hospitals and highlights the critical role of vascular access nurses in the implementation of appropriateness criteria, reducing insertion delays, ensuring robust in-hospital PICC care, and providing discharge education. However, our findings also reveal variation in practice and opportunities within each process domain to improve care delivery and patient safety.

The importance of dedicated vascular access teams for ensuring safe and effective PICC use is not novel. Prior studies show that PICC placement by vascular access teams is associated with fewer insertion complications and can be cost-saving.^19–23 Having a vascular access team has also been associated with greater use of evidence-based CLABSI prevention practices,⁷ and low complication rates.^{8, 9} Yet, our results also demonstrate the important role these teams play across the continuum of care for patients with specialized vascular access needs. This includes guiding device use in accordance with appropriateness criteria; preventing care delays by being more readily available when PICC placement is required; and, managing device-related complications, such as occlusions, that can result in treatment interruptions or premature device removal. Finally, vascular access teams appear to be an integral part of preparing patients to perform critical self-care tasks post-discharge. These findings add to current knowledge by highlighting the multiple roles of vascular access teams as a hospital resource and provide the elements for a business case for team investment given the potential savings from preventing harm and improving device use.

PICC use begins with the vascular device decision, which requires considering factors related to complication risk, including the required therapy, infusion duration, device type and patient factors.¹ Our findings indicate that sites with vascular access teams had generally well-defined decision-making processes. This included specialist consultations to determine therapy type and/or if a PICC was appropriate based on patient characteristics such as presence of chronic kidney disease. However, specialist involvement in decision-making was more variable or even lacking at the non-vascular access team sites. Studies suggest that PICCs are inappropriately used in patients with renal dysfunction²⁴ or for patients who may not need a PICC for parenteral antimicrobial therapy post-discharge.²⁵ Thus, interventions that promote and facilitate specialist consultation prior to PICC insertion could be important, especially at sites without vascular access teams, to reduce potential hazards.²⁶

Vascular access team sites also used explicit decision-making criteria, namely MAGIC,¹ which emerging evidence suggests is associated with improved safety and lower overall PICC use.^{5, 27, 28} Nonetheless, many ordering clinicians were not aware that appropriateness criteria existed, and no formal criteria were used at the non-vascular access team sites. This finding suggests a universal need for better education and strategies to seamlessly facilitate decision-making, such as embedding appropriateness criteria as part of a PICC order set, as was done at one vascular access team site. However, implementing appropriateness criteria also requires that alternative devices, such as midlines or ultra-sound guided peripheral IVs, are available, which was not the case at all sites. Additionally, alternative use at some sites was limited by clinician lack of awareness, or perceived lack of usefulness. Increasing awareness, availability and use of alternatives could therefore be another strategy for improving patient safety.^{29, 30}

A notable difference in PICC insertion processes, especially between sites with and without vascular access teams, was the potential for care delays. Such delays were most striking at the site without on-site insertion capability, as patients had to be transported to another facility for PICC insertion. However, potential delays were also described at sites with primarily IR insertion due to lack of 24/7 IR clinician availability and PICC insertion being just one of many IR procedures. Concerns about delays were less common at vascular access team sites. Yet, one hospital was reducing vascular access team hours based on productivity (i.e., number of devices placed within a certain timeframe) and concerns about nursing staff maintaining proficiency with inserting peripheral IVs, while the other was increasing team availability by broadening the range of dedicated responsibilities to include responding to in-hospital cardiac arrests and providing nearly full-time vascular device management across the facility. These contrasting cases suggest a need for further research to assist hospitals in identifying strategies to capture return on investment related to developing and deploying vascular access teams.

In-hospital PICC care also differed across sites. At all sites, RNs only were authorized to provide PICC care, although task delegation, scope of authorized practice and level of competency varied. At hospitals with vascular access teams, the team RNs were responsible for many aspects of PICC-related care, including daily line checks, line malfunction management, and removal. However, bedside RNs were also part of the process, conducting regular assessments, blood draws, and as-needed dressing changes. At one of the hospitals without a vascular access team, a dedicated IV team functioned in much the same way. These models ensure that individuals with specialized knowledge oversee and perform critical management tasks to ensure optimal device care and function. On the other hand, maintaining competency and comfort with PICC care among bedside RN staff is also critical given limited or in some cases no availability of these highly specialized providers. Thus, strategies to ensure competency are needed, especially at sites with low-volume PICC use. This could include regular competency assessments, as well as developing linkages between sites with and without vascular access teams for consultation and ongoing education and training.

Home infusion therapy relies on patients and/or their informal caregivers performing vascular device self-care,^{15, 16} tasks often learned just prior to hospital discharge. Our study suggests there are no clear standards for teaching patients about PICC care as well as variation in discharge processes and post-discharge care across hospitals. Hospitals with vascular access teams had specific discharge teaching approaches and materials, including skills-based training (e.g., device flushing). However, the process appeared haphazard at non-vascular access team sites, including lack of clarity about who had primary responsibility for PICC-related discharge education and educational content. While some of these shortcomings might be addressed by home care providers, the skill level and availability of these providers also varies.^{31, 32} Given the importance of PICC-related self-care tasks in the delivery of safe, effective home infusion treatment, these gaps in discharge education and post-discharge care represent a critical area for further research as well as a clear opportunity for care improvement. This includes developing discharge specific interventions as well as ways to support care outside the hospital, which could involve the use of virtual visits or technology.^{33, 34}

Our study has limitations. We conducted site visits and interviews with healthcare personnel at five purposefully selected VA Medical Centers. While these Medical Centers were selected in accordance with the predominant types of PICC insertion models based on prior research,⁷ this selected sample is not intended to be broadly generalizable or even representative of all VA Medical Centers or U.S. acute care hospitals. Another limitation is the potential for response bias. To minimize potential bias, we interviewed individuals with a diverse set of organizational roles and thus varying perspectives and experiences related to PICC use at their facility. We also need to acknowledge that this work is largely descriptive and does not provide a deep analysis of the underlying factors driving the observed variation across hospitals. Finally, our interpretation of the findings and recommendations for improvement may reflect certain underlying biases based on the research team composition and perspectives. To mitigate this risk, our team was highly disciplinary and comprised of two physicians, one nurse and four non-clinicians.

Our qualitative study identifies key aspects involving decisions about PICC use, the insertion process, PICC management and patient discharge education that benefit from the presence of a vascular access team. We found notable practice variations across hospitals and specific areas for both care improvement interventions and further research. This includes developing and evaluating strategies that: improve clinician awareness and use of PICC appropriateness criteria and alternatives, inform the efficient and effective deployment of dedicated vascular access teams, and address deficits in the patient discharge education process. Moreover, this research indicates that ongoing attention and rigorous practices across all the key process domains remains essential for ensuring appropriate, safe and effective PICC use.